Live Discussion with Dr Jen Kanady - 2 October 2019

Dr Kanady will be hosting a live online discussion here on Wednesday 2 October, from 8.00pm to 9.30pm British Time or 3.00pm to 4.30pm US Eastern Time.

They will discuss as many topics as possible in the hour and, as always, you are welcome to ask any questions at all about sleep or the Sleepio program. If there are a lot of questions, they may not be able to answer all in the time available, but will try to answer as many as they can.

Please do note that, as per our guidelines, Dr Kanady will not be able to give personal medical advice including those about medication. Their replies to questions will be made in such a way as to help as many people as possible who might have similar issues.

To keep up with new comments as they are posted you will need to refresh this discussion page.

Posted 27 Sep 2019 at 3:00 AM
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  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Hi johnhassan,

    Thanks for the great question, especially as early morning awakenings can be quite common!

    Early morning awakenings can be tricky because sometimes it’s a matter of biology. Due to differences in circadian rhythms, some individuals are predisposed to be a “lark” or a “morning person.” In the sleep field, this phenomenon is referred to as “advanced sleep phase” or a “morningness circadian preference.” This shift in the circadian rhythms can become even more pronounced as we age.

    Here is a nice article about circadian preferences: https://www.sleepio.com/library/article/do-you-really-get-people-who-are-owls-and-others-w/

    There are a couple of techniques that may be helpful for addressing early morning awakenings. One possibility is shifting the bedtime later, thereby increasing the need for sleep and making it more likely to sleep past the typical early morning awakening time. Once the target wake time is achieved, I generally recommend shifting the bedtime earlier until achieving the desired sleep window. This is what you will do as part of the sleep restriction protocol in Sleepio. Another possibility is embracing the early morning awakening and shifting the bedtime earlier to account for the earlier rise time. Another thing that can be helpful for early morning awakenings is capitalizing on the impact of light and dark conditions on circadian rhythms. More specifically, evidence suggests that dim light conditions are best when winding down at night and bright light conditions are best first thing in the morning. Reducing exposure to light during times when you want to be asleep can be helpful for adjusting the circadian rhythm to a schedule that is more desirable for you.

    Here is a nice community post that further discusses early morning awakenings: https://www.sleepio.com/community/discussion/early-awakening/

  • Sleepio Member

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    Expert

    Hi Glisglis,

    Great question, thank you for asking! When adjusting to the upcoming time change (i.e., the end of Daylight Saving Time), I think either approach is just fine. In an ideal world, my recommendation would be to adjust the sleep window gradually. E.g., shift the sleep window by 15 minutes per week. A more gradual adjustment would likely create less of a “shock to the system.” However, not everybody has this option due to occupational and social obligations. For these cases, I think that it is fine to shift the sleep window all at once. In this case, you may feel a bit “out of sorts” for the first few days as the circadian rhythm adjusts to the new external time. However, as long as you are keeping the bedtime and rise time consistent, the circadian rhythm should adjust to the hour change fairly quickly.

  • Sleepio Member

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    Expert

    Thanks for your comment and great suggestion! Another thing you can do during early morning awakenings is to get out of bed and do something relaxing and only return to bed once you feel sleepy. The important thing to keep in mind with this approach is that you want to do your best not to sleep past your typical rise time to make up for the sleep lost. Sleeping in destabilizes the circadian rhythm and can interfere with sleep.

    Thank you for raising this point!

  • Sleepio Member

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    Expert

    Hi Lulapop,

    I am sorry to hear that you are struggling with your sleep again, that can be really frustrating.

    Honestly, there is no perfect approach to reintegrating the Sleepio skills and my general advice is doing what makes the most sense for you.

    Sleep restriction is the most powerful skill taught in Sleepio and is a great way to get your sleep back on track quickly. However, as I am sure that you remember, sleep restriction can also be incredibly challenging and can be stressful for a lot of people. If sleep restriction feels overwhelming at this time, then my suggestion would be to start by keeping a regular sleep/wake schedule. This would help to stabilize the circadian rhythms, which can help with initiating and maintaining sleep. From there, you could then try to restrict the sleep window to the actual amount of time you spend sleeping. Again, there is no “one size fits all” approach and it is up to the user to figure out what makes the most sense.

    Please do feel free to check back in as you progress through the program!

  • Sleepio Member

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    Expert

    Hi SleepioUser,

    I am sorry to hear that you are struggling. Week 3 of the Sleepio program is definitely the most challenging as both sleep restriction and the quarter of an hour rule are introduced.

    While these skills are meant to promote sleep, sometimes they can also introduce additional things to worry about, which makes sleeping harder … counterproductive indeed! A couple of thoughts about this. First, the quarter of an hour rule is meant to be interpreted subjectively. That is, this rule is not meant to be exact and it is generally recommended that the users estimate how long they have been awake rather than watching the clock and trying to be exact. Second, it is important that the activities done outside of the bed as part of the quarter of an hour rule are relaxing and are done in dim light conditions (e.g., relaxation exercises, listening to music, coloring). It sounds like you are already doing a great job with this! Third, there is room to get creative with the quarter of an hour rule. For example, if you find that leaving the bedroom is too stimulating, you can try relocating to the bedroom floor or a chair in the bedroom. Some people have also noted success just moving to the other side of the bed. Fourth, if the quarter of an hour rule is causing significant distress, then my recommendation would be to start with sleep restriction only. Sleep restriction is meant to increase the sleep drive, thus making it easier to fall asleep and stay asleep. If working correctly, sleep restriction can eliminate these periods of prolonged wakefulness in bed, making the quarter of an hour rule obsolete!

    Please feel free to reach back out with any additional questions or concerns.

  • Sleepio Member

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    Expert

    Hi livingbeyond135,

    It sounds like you are engaging in a lot of really healthy practices, that’s great to hear!

    The thing about nocturnal awakenings to keep in mind is that they are to be expected! Everybody wakes up in the middle of the night, but not everybody is able to remember those awakenings. When nocturnal awakenings become problematic is when the awakenings last for 30 minutes or longer and/or when these awakenings are causing significant daytime impairment/distress.

    Sleep restriction is one of the best ways to reduce nocturnal awakenings. Reducing time in bed increases the sleep drive and makes it more likely that a person will sleep through the night. However, if nocturnal awakenings are not causing significant distress, then sleep restriction may be unnecessary. For people who wake up but are able to fall back asleep within 15 or so minutes, I generally think that sleep restriction may be unnecessary. But of course, it is up to the users’ discretion to do what makes most sense for them.

  • Sleepio Member

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    Graduate

    As it happens, I arrived on my own at your fourth suggestion (skipping the quarter hour rule) last night in my desperation to get some sleep of any kind. I decided when I went to bed to skip getting up if I couldn't sleep – and slept solidly through the night! If/when this no longer works, I'll try your #3 as well. Great suggestions, thanks!

  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Hi Leejohn,

    Thanks for your question. This is probably such a typical sleep psychologist thing to say, but here it is: All sleep is good sleep!

    During sleep we pass through four different sleep stages. We have the NREM sleep stages: sleep stage 1, sleep stage 2, and slow wave sleep. And then we also have REM sleep. Each of these sleep stages serve an important function and I wouldn’t necessarily say that one sleep stage is better than the other.

    What is true, however, is that we tend to get the majority of our slow wave sleep during the first half of the night. Slow wave sleep is the deepest and most restorative sleep stage. It’s the sleep stage that helps us to feel refreshed the following day.

    You also mentioned that you wake up several times throughout the night, but are able to return to sleep quickly. That is actually completely normal and is to be expected. Everybody wakes up in the middle of the night, but not everybody is able to remember those awakenings. Waking up in the middle of the night only becomes problematic when these awakenings are prolonged and/or if they cause significant distress or impairment.

    Expectation management can be helpful for individuals who experience shorter nocturnal awakenings (e.g., understanding that these awakenings are typical and unavoidable). Also, worries about these awakenings might be a nice opportunity to practice those cognitive skills learned is session 4 and 5 of Sleepio.

  • Sleepio Member

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    in reply to Sleepio Member
    Graduate

    Thanks so much for your reply to my question. That is helpful.

  • Sleepio Member

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    Expert

    Thanks for your comment, Eddie06. Please see my response to Leejohn above.

    To add to my original response:

    We tend to get the majority of our slow wave sleep during the first half of the night. We tend to get the majority of our REM sleep during the second half of the night. Slow wave sleep is the deepest sleep stage and is important for things like muscle regeneration and memory consolidation. REM sleep is the sleep stage most associated with dreaming. REM sleep is important for things like emotion regulation and creativity.

    While these are the two most well known sleep stages, what a lot of people don't realize is that the majority of our sleep period is actually made up of stage 2 sleep, which is another important sleep stage. For example, stage 2 sleep is important for consolidating procedural memories (e.g., learning a new skill).

    Stage 1 sleep is the lightest sleep stage and is important for transitioning from wake to sleep.

    In sum, each sleep stage serves an important function. Hope this helps and thanks for giving me the opportunity to nerd out about sleep!

  • Sleepio Member

    • 2 comments
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    Session 4

    I’ve taken 10 12.5 mg Ambien CR over the past 16 days. I know that they will eventually stop helping me sleep, but I am anxious to stop using them on work days. Do you recommend stopping this medication cold turkey or should I try to take it every other work day to wean?

    I am also worried about rebound insomnia. Would rebound insomnia occur only after taking the medication for 10 days?

  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Hi Kathryn Silvestre,

    Please see my response to Arabella's message above.

    To summarize: The general rule of thumb is to avoid daytime napping because napping depletes the sleep drive and makes it more difficult to initiate and/or maintain sleep that night.

    However, like with any rule, there are important exceptions! Sleep problems often coexist with other medical conditions like MS, pain, and chronic fatigue. In these instances, I generally tell individuals to do what makes the most sense for them. For example, if napping is the only thing that provides relief, then I typically say go for it. My one recommendation in these cases would be to keep the naps earlier in the day (ideally before 3:00 PM) and to limit the naps to no more than 30 minutes. By doing this, you will impact the sleep drive less. Of course, I realize that this is not always feasible and it is up to the user to decide what makes the most sense for them.

  • Sleepio Member

    • 3 comments
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    Graduate

    I have another question for you. How long on average does it take someone’s body to adjust to a new sleeping pattern (assuming you are 100% dedicated to the new times). I’ve heard up to two weeks is a relative normal range for jet lag, is it similar for adjusting to a new sleeping schedule?

  • Sleepio Member

    • 394 comments
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    in reply to Sleepio Member
    Expert

    Hi Dadakoul,

    Thanks for reaching out.

    Please see my response to SleepioUser:

    A couple of thoughts about this. First, the quarter of an hour rule is meant to be interpreted subjectively. That is, this rule is not meant to be exact and it is generally recommended that users estimate how long they have been awake rather than watching the clock and trying to be exact. Second, it is important that the activities done outside of the bed as part of the quarter of an hour rule are relaxing and are done in dim light conditions (e.g., relaxation exercises, listening to music, coloring). Third, there is room to get creative with the quarter of an hour rule. For example, if you find that leaving the bedroom is too stimulating, you can try relocating to the bedroom floor or a chair in the bedroom. Some people have also noted success just moving to the other side of the bed. Fourth, if the quarter of an hour rule is causing significant distress, then my recommendation would be to start with sleep restriction only. Sleep restriction is meant to increase the sleep drive, thus making it easier to fall asleep and stay asleep. If working correctly, sleep restriction can eliminate these periods of prolonged wakefulness in bed, making the quarter of an hour rule obsolete!

    And in terms of your sleep restriction question, if you don't achieve a 90% sleep efficiency, the sleep window often stays the same. It is also important to note that everybody adjusts to the sleep window at a different pace. For some individuals, it may take several weeks for their circadian rhythms to adjust to the new schedule. In these cases, I usually encourage individuals to do their best to stick to the program.

    Please feel free to reach out with any additional questions and/or concerns.

  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Hi goateeking,

    Thanks for the great questions. For your question about the upcoming time change, please see my earlier response:

    When adjusting to the upcoming time change (i.e., the end of Daylight Saving Time), I think either adjusting gradually are all at once is just fine. In an ideal world, my recommendation would be to adjust the sleep window gradually. E.g., shift the sleep window by 15 minutes per week. A more gradual adjustment would likely create less of a “shock to the system.” However, not everybody has this option due to occupational and social obligations. For these cases, I think that it is fine to shift the sleep window all at once. In this case, you may feel a bit “out of sorts” for the first few days as the circadian rhythm adjusts to the new external time. However, as long as you are keeping the bedtime and rise time consistent, the circadian rhythm should adjust to the hour change fairly quickly.

    Great question about passive activities. The recommended passive activities are meant to serve as a rough guideline and there is certainly room to play and be creative. You are absolutely right, some books might be very boring while some television shows might be engaging and may prevent sleep. Podcasts inevitably vary in their level of stimulation too. I agree that keeping content in mind is important for deciding what activity is appropriate as part of the wind down period.

  • Sleepio Member

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    in reply to Sleepio Member
    Expert

    Hi Dadakoul,

    These are really important questions. Unfortunately, I am unable to offer any guidance on how to proceed with your sleep medications. My recommendation is that you speak with your prescribing physician before making any changes. Also, it is difficult to predict whether you will experience rebound insomnia as everybody's experience is different.

  • Sleepio Member

    • 394 comments
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    in reply to Sleepio Member
    Expert

    Hi again and another great question!

    Unfortunately, there is no one answer to this question. Everybody adjusts to the sleep window at a different pace. For some individuals, it may take several weeks for their circadian rhythms to adjust to the new schedule. In these cases, I usually encourage individuals to do their best to stick to the program (e.g., maintain a regular rise time even on non-work days, avoid taking daytime naps) to encourage a quicker adjustment.

  • Sleepio Member

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    Graduate

    Thank you very much for your help Dr. Kanady!

  • Sleepio Member

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    Expert

    Signing off now. As always, it was a wonderful discussion. For any outstanding questions or concerns, please feel free to take advantage of the next live expert chat next Wednesday.

    Happy sleeping.

  • Sleepio Member

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    in reply to Sleepio Member
    Graduate

    Thanks Dr Kanady

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